Professional Documents
Culture Documents
Asthma
Definition
Diagnosis and Classification
Asthma Medications
Asthma Management and
Prevention Program
Asthma
Chronic inflammatory disorder of
airway
Airway hyper-responsiveness
Widespread, but variable, airflow
obstruction within lung that is
reversible
Mechanisms: Asthma
Inflammation
Airway smooth
muscle
Hypertrophy
Hyperplasia
Edema
Contraction
Mucus
hypersecretion
Airway
hyperresponsivenes
s
Pathogenesis of asthma
Intermittent airway constriction
Airway inflammation
Bronchial hyperresponsiveness
Environmental Factors
Genetic
- Atopy
- Airway
hyperresponsiveness
Gender
Obesity
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet
Classification of asthma
1. Allergic asthma (extrinsic asthma)
childhood onset and seasonal variation
history of allergy to a variety of inhaled
factors
Is it Asthma?
Recurrent episodes of wheezing
cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants
Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to
identify risk factors
X 100%
Differential diagnosis
COPD
Acute pulmonary edema
Foreign body aspiration
Gastroesophageal reflux
Bronchiectasis
Vocal cord dysfunction
Endobronchial mass
2
3
4
Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue
medication
Normal lung function
No exacerbations
_________
Controlled
Partly controlled
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal
symptoms /
awakening
None
Any
Normal
None
More than
twice / week
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any week
Goals of Long-term
Management
Achieve and maintain control of
symptoms
Maintain normal activity levels
(+exercise)
Maintain pulmonary function~ normal
levels
Prevent asthma exacerbations
Avoid adverse effects from
medications
Prevent asthma mortality
Controller Medications
Beclomethasone
200-500
100-200
>500-1000
>200-400
Budesonide
200-600
200
100-
600-1000
>200-400
Budesonide-Neb
Inhalation Suspension
Ciclesonide
250500
80 160
>500-
>400
>400
>1000
1000
80-160
>160-320
>160-320
>320-1280
>750-1250
>2000
>1250
>200-500
>500
>500
Flunisolide
500-1000
750
500-
>1000-2000
Fluticasone
100-250
200
100-
>250-500
Mometasone furoate
200-400
200
100-
> 400-800
>200-400
>800-1200
Triamcinolone acetonide
400-1000
800
400-
>1000-2000
>800-1200
>2000
>320
>400
>1200
Reliever Medications
Rapid-acting inhaled 2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest
controlling step
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
Patient Education
key components of successful asthma
management
how to monitor their symptoms and
pulmonary function
what triggers asthma attacks and how to
avoid
what medicine to take and how to use
inhalers
what to do in the emergency events
Mild
Walking
Breathless
Can lie down
Talk in
Alertness
Sentences
May be agitated
Respiratory rate
Increased
Accessory
muscles
Usually not
Wheeze
Often only
expiration
Pulse rate
< 100
Pulsus
paradoxus
Absent < 10
PEF after BD
( % predicted or
% personal best )
Over 80%
Normal
< 45 mmHg
> 95%
Moderate
Severe
Respiratory
arrest
Mild
Moderate
Severe
At rest
Breathless
Hunched forward
Talk in
Alertness
Words
Usually agitated
Respiratory rate
Accessory
muscles
Usually
Wheeze
Usually loud
Pulse rate
> 120
Pulsus
paradoxus
Often present
PEF after BD
< 60 % or
( % predicted or
% personal best )
Respiratory
arrest
Mild
Moderate
Severe
Respiratory
arrest
Breathless
Talk in
Alertness
Drowsy or
confused
Respiratory rate
Accessory
muscles
Abdominal
paradox
Wheeze
Absence
Pulse rate
Bradycardia
Pulsus
paradoxus
Absent
PEF after BD
( % predicted or
% personal best )
Asthma exacerbations
Medication
Treatment
Remark
Rapid-acting
inhaled
2-agonists
+ NSS 2 ml
Medication
Treatment
Ipratropium
Remark
Produce better bronchodilation than
either drug alone
bromide
in combination of 0.5 mg or 0.5-1 ml or 0.5-1 nebule q 4-8
hr
NB
MDI + spacer 2-8 puffs q 4-8 hr
-agonists
2
Theophylline
Minimal role :
- Severe side effects
- Bronchodilator effect < 2-agonists
Benefit as add-on treatment is not clear
Medication
Treatment
Remark
Systemic
glucocorticosteroids
Medication
Treatment
Remark
Inhaled gluco- Effective as part of exacerbation
corticosteroids As effective as oral steroid to prevent relapses
High-dose ICS (2.4 mg budesonide daily)
relapse rate similar to 40 mg oral prednisone daily
Pts discharge with prednisone + inhaled
budesonide was lower relapse rate than those on
prednisone alone
Medication
Treatment
Epinephrine
Magnesium
(MgSO4 2 g iv over 20 min)
Remark
Not routinely indicated
Not recommended for routine use
Reduce hospitalization in adults
with FEV1 25-30% predicted, fail to
initial Rx
NB salbutamol in isotonic MgSO4
greater benefit than in NSS
Helium oxygen
therapy
No routine role
Sedatives
Asthma exacerbations
Asthma exacerbations
Asthma exacerbations
After discharge
Minimum 7-day course of oral steroid
As-needed bronchodilator until return to
normal
Continue ICS
Review inhaler technique and use of PEF
meter
Precipitating factor should be identified and
avoided
Assess severity
Initial management
Asthma